Some upheld, recommendations

Summary

Mr C has complex needs and requires long-term care and specialist input. He has severe dementia, with limited capacity to judge distance or to understand and participate in therapies, and his wife (Mrs C) has welfare power of attorney for him. Mr C can move about, but is at particular risk of falling. In November 2007 Mr C was admitted to a continuing care ward, where he remains a patient. Mrs C made a number of complaints about aspects of the care and treatment that her husband has received. These included the actions the board took to address Mr C's condition in February 2011, medication, observation and monitoring, staffing levels, carer communication, charting and record-keeping, the standard of bathroom facilities and complaints handling.

Our investigation included taking independent advice from two of our medical advisers - one in mental health and one a GP. We took account of this advice as well as evidence from Mrs C and the board. Mrs C said that in February 2011 her husband became very unwell and staff failed to take reasonable measures to bring his temperature down and call a doctor within a reasonable time. Our investigation found that staff took appropriate action when Mr C became unwell and that their interventions overall were reasonable. In relation to the drug regime and administration, however, although we found that the principal contributing factor to Mr C's falls was most likely to have been involuntary muscle twitching, we also found that there were significant failings. These included the discontinuation of an antidepressant for three weeks; the timing of medication; and failure to ensure Mr C received prescribed medication when off the ward. We also found that the board failed to administer flu vaccinations to Mr C, either within a reasonable time or at all, placing his physical health at risk.

Mrs C also said that the board failed to ensure that Mr C was sufficiently hydrated (had enough fluids). We found that throughout the period Mr C was well hydrated and had effective liver and kidney function, but that there were inconsistencies in recording and monitoring his fluid balances. We also found that the board failed to properly assess Mr C's falls risk or properly record or implement a fall prevention care plan.

Mr C was sedated because he wandered at night due to agitation, and Mrs C felt that this could have been managed without resorting to sedation if there were more staff. We did not uphold this complaint as we found that, while it was difficult to reach a definitive conclusion on whether staffing levels were reasonable, staff used sedating medication as a last resort and then only rarely. In relation to Mrs C's complaint about bathroom facilities, the evidence available suggested that the ward is cleaned to an acceptable standard and that any problems are addressed within a reasonable time.

Mrs C said that staff communication about assessment of her husband's capacity and administration of sedative drugs was inadequate and she was also concerned that a 'do not attempt to resuscitate' certificate (DNAR - showing that a doctor is not required to resuscitate the patient if their heart stops) was signed by medical staff without her input. We upheld this complaint as we found that communication with Mrs C was not of a reasonable standard and did not comply with the Adults with Incapacity legislation. The board's record-keeping was also of concern and we found that at times it fell below a reasonable standard and did not, amongst other things, record a reasonable standard of communication with Mrs C. We also found instances of statements in the board's complaints responses that were either inaccurate or misleading, indicating that Mrs C's complaint was not investigated as thoroughly as it should have been.

Recommendations

We recommended that the board:

• implement measures to avoid patients being given medication at the end of one medication round and the beginning of the next, thereby ensuring an appropriate period of time has elapsed between doses;
• implement checking mechanisms to ensure the prescription sheets are transcribed accurately;
• ensure patients authorised to be off-the-ward receive medication consistently as prescribed by medical staff;
• review the processes for managing, prescribing, administering and recording in relation to the flu vaccination;
• ensure that falls prevention procedures, including developing and evaluating falls prevention plans, are consistent with the board's policy;
• ensure effective systems are in place to keep staffing levels under review;
• take measures to ensure appropriate compliance with the Adults with Incapacity Act, with particular regard to DNAR decision making and communication with relative or carers;
• ensure that relatives' communication documentation is used consistently to record the nature and content of discussion with relatives or carers;
• build flexibility into the charge nurse's appointment system so that there are opportunities for communication outwith scheduled times to deal with issues as they arise;
• ensure that record-keeping reflects the care and medication given and a reasonable standard of communication;
• consider implementing unplanned visits to ensure a reasonable standard of hygiene;
• ensure complaints are investigated thoroughly and that responses are accurate; and
• apologise to Mrs C for all the failings identified in our investigation.

Summary

Miss C had been receiving a repeat prescription for tablets. However, on one occasion when she visited the pharmacy the pharmacist said the prescription could only be collected on certain dates, and that the next date had not yet arrived. Miss C had not been advised of this previously. The pharmacist gave Miss C five tablets to last until she could pick up her next prescription, although Miss C did not need that many tablets.

Miss C complained to us that the pharmacy applied rules about collection inconsistently and that although they had said there were dosage concerns, they then inconsistently issued more tablets than required. She was also unhappy with the way in which her complaint was handled.

We did not uphold Miss C's complaint about the inconsistent application of rules and issue of tablets. Our investigation found that the pharmacist was required to follow the advice of the prescribing doctor which in this case, was to provide a fortnight's supply of tablets every 14 days. The pattern of prescribing appears to have become slightly out of sync when the last prescription was written, leading to the change in dates. We did, however, make a recommendation to try to avoid this happening to someone else in future.

We upheld the complaint about complaints handling. Although the pharmacy acknowledged Miss C's complaint within their timescales, they did not respond to her until more than ten working days after receiving it, which was outside the recommended time limit. The pharmacy's head office, where the complaint was handled, is in England, and they failed to give Miss C information about the Scottish NHS complaints system and the Ombudsman.

Recommendations

We recommended that the pharmacy:

• provide staff with guidance that ensures that they clearly explain the prescribing regime to patients with repeat prescriptions, as well as indicating the dates on which patients can collect such prescriptions; and
• apologise to Miss C for failing to provide the correct information when responding to her complaint, and for the delay in responding.

Summary

Mr C complained about the board on behalf of his daughter (Miss A) who had been referred to the board's Child and Adolescent Mental Health Service (CAMHS) when she was 15. Mr C and his wife attended some of the consultations with her. Miss A was prescribed with fluoxetine (a medicine used to treat a variety of mental health problems) and subsequently discharged from the service.

Four years later, Miss A was diagnosed with bipolar disorder (a condition affecting a person's moods). Mr C considered that CAMHS should have diagnosed this when Miss A saw them four years earlier. He complained to us that that the assessment and treatment package provided by CAMHS did not meet his daughter's needs and that that they did not listen to him and his wife.

Our investigation included taking independent advice from one of our medical advisers. We upheld part of Mr C's complaint, as we found that the treatment provided to Miss A by CAMHS was reasonable, but that there were a number of deficiencies in the records. In particular, there was no record of the action taken by the psychiatrist who briefly saw Miss A and no record of any formal mental state examination. Staff also failed to explicitly state the diagnosis, treatment plan and prognosis. However, the records made at the time indicated that the clinicians had listened to and reported the concerns of Miss A's parents while she was being seen by CAMHS. There was no indication that Miss A showed any symptoms or signs that were specific to the diagnosis of bipolar mood disorder at that time and there was no reason to diagnose this. The only diagnosis that appeared to be applicable during that period of assessment was of a depressive disorder. Given this, bipolar mood disorder would have been a risk for the future, but one amongst a number.

Recommendations

We recommended that the board:

• issue a written apology for the deficiencies in Miss C's records; and
• review the record-keeping in CAMHS to try to ensure that such failures are no longer occurring.

Summary

Ms C was in the later stages of her first pregnancy, and was expecting twins. She went to hospital because she had vaginal bleeding. She was admitted for a consultant review and discharged home the following morning. Six days later she went into advanced labour and delivered both babies, but one of her twins died shortly after birth. Ms C complained to us about her care both before and after the birth.

Ms C's complaint had several elements, including inadequate care of a pre-eclampsia risk (a condition involving a combination of raised blood pressure and protein in the urine); inadequate care during two admissions which she said resulted in the premature birth of her twins and the death of her son; inadequate care and treatment for a post-natal haemorrhage (bleeding) and subsequent removal of products; poor record-keeping and delays in holding a clinical risk review (CRR).

Our investigation included taking independent advice from one of our medical advisers. We took account of this advice along with all the evidence provided by Ms C and the board, which included an internal report and two externally commissioned consultant reviews. Our investigation found no evidence of any failure that resulted in Ms C giving birth prematurely or any failure in care that resulted in the death of one of Ms C's twins. We also did not find any evidence of clinical failure with Ms C's post-natal care, but we did acknowledge that there were documentation failures and delays in holding the CRR.

Recommendations

We recommended that the board:

• ensure that the details of a speculum examination are fully documented to include the reasons if a cervix cannot be visualised and the rationale with regard to antenatal corticosteroids; and
• ensure the full documentation of all treatments delivered to patients is appropriately and timely recorded by those in attendance as soon as is feasibly possible, with specific reference to emergency situations.

Summary

Ms C complained that the care and treatment provided to her mother (Mrs A) was inadequate. Mrs A suffers from multiple sclerosis (MS) which is a degenerative disease affecting the nervous system. Sufferers can have various difficulties including mobility, digestive system and urinary problems.

In November 2010, Mrs A was hospitalised with a severe urinary infection which later developed into septicaemia (a serious bacterial infection). She was in several hospitals until early 2011. Ms C complained that, during her mother's time in hospital, the board failed to provide an adequate level of physiotherapy; failed to provide a reasonable level of specialist MS nursing care; failed to adequately communicate with the family, and failed to respond appropriately to Ms C's complaint.

Our investigation included taking independent advice from two medical advisers - a physician and nephrologist (kidney specialist) and a senior nurse with experience in neurological and neurosurgical nursing (treating illness or injury affecting the nervous system). We found that an appropriate level of physiotherapy and MS nursing input had been provided to Mrs A during her hospital stay.

Mrs A was, at times, very unwell and our medical advisers considered that the important thing was to address her acute symptoms of infection. When Mrs A was able to engage with the physiotherapy team, therapy was provided. Although the MS nurse only visited Mrs A once during her stay, the nursing adviser considered that there would have been no added value from further input at the time.

We found that Mrs A's MS was regularly and appropriately reviewed during her hospitalisation. However, the physician adviser felt that there was no evidence of communication between the doctors and Mrs A and her family. There were some records of communication from nursing staff but Ms C still felt that communication in general had been poor. The board had responded that next of kin are not automatically entitled to information about a patient and the patient's confidentiality had to be protected. However, our investigation found that guidance from the General Medical Council states that while patient confidentiality should be considered at all times, common sense should also prevail when a patient is very ill and unable to either give or withhold consent to share information with their family. In this case, Mrs A was at times very ill indeed and the advisers thought that staff should have used common sense in their communication with the family.

Ms C was also dissatisfied with the time taken to respond fully to her complaint and said that there were inaccuracies in the final letter from the chief executive. Our investigation confirmed that the timescales for responding to Ms C's complaint had been breached without her being kept up to date and that there were inaccuracies in the letter.

Recommendations

We recommended that the board:

• apologise for the failings in communication and complaint handling identified;
• make staff aware of and adhere to relevant guidance on communication with family/carers/loved ones; and
• make staff aware of and adhere to the guidance on complaints handling.

Summary

Mrs C complained on behalf of a village hall committee about Business Stream. She was unhappy with the water services the committee had been given. In particular, she said that their water meter had not been read for over a year, significantly increased consumption had not been brought to their attention and that Business Stream had failed to communicate adequately with the committee. She also alleged that Business Stream took a large amount of money from the committee's bank account by direct debit, without warning, when their water account was supposed to be on hold.

In investigating the complaint we took all relevant information into account, including statements of account, details of meter readings and customer correspondence etc. We did not, however, uphold most of Mrs C's complaints. We found that the meter had not been read between December 2009 and June 2011 although Business Stream had a statutory obligation to take a meter reading at least once a year. However, we found that after the December 2009 reading, a reading was intended to be taken in December 2010. This, however, was prevented by adverse weather conditions on the day, which were well documented, and so the meter was next read on 19 June 2011. In the circumstances, we did not consider this unreasonable. During the period when the meter was not read, estimated bills were issued. After the reading in June 2011 a bill was issued based on the reading, which reflected very high comparative usage. Although Mrs C argued that their use of water had not changed, neither the committee nor Business Stream could find a problem with the meter. Business Stream explored other possible explanations for the spike in usage but found nothing. They, therefore, concluded that the apparent increase in use reflected the catch-up required after the committee had been sent a number of estimated bills.

On balance, we concluded that this was a reasonable position to take. While Mrs C complained about the way in which Business Stream communicated with the committee, and said that one of their letters had gone unanswered, we found that they had not in fact received this letter. Otherwise, our investigation showed that all correspondence and phone calls were replied to. We found that Business Stream placed the committee's account on hold pending the outcome of the investigation into the complaint but, meanwhile, more than £2000 was taken from the committee's account by direct debit. Although Business Stream confirmed that the account had been placed on hold, they had not stopped requesting the direct debit. We took the view that this would be a customer's normal expectation in the circumstances and so we upheld this

Recommendations

We recommended that Business Stream Ltd:

• make a formal apology reinforced by a payment of £50; and
• seek to prevent such a situation recurring. Alternatively, they repay to the customer the amount of any direct debit taken under such circumstances as soon as the situation becomes known and while a complaint is still under investigation.

Summary

Mr C complained that Business Stream did not give him notice that the water pressure at his business premises would be much higher when Scottish Water upgraded the pipes in his area. He said that there were a number of large underground leaks in his premises, and it took him several months to detect and fix all of them. As a result of this, his water bill rose substantially, although he was given a rebate sum for part of this.

We asked Business Stream if either they or Scottish Water should tell customers if the pressure in the network is to increase. Business Stream said that Scottish Water manage their network on a daily basis, which increases and decreases pressure. They said that Scottish Water do not advise if there are to be changes unless the change in water pressure is to be so great that it would cause an operating issue to a commercial customer. They told us that Scottish Water renewed the old pipe work in Mr C’s area, but did not increase the water pressure there, although the new pipe work increased the water pressure at Mr C’s premises due to increased efficiency and reduced water loss. However, there was no requirement in these circumstances for Business Stream or Scottish Water to give him notice about this so we did not uphold that complaint.

Mr C also complained that Business Stream failed to deal with his complaints appropriately and delayed in reading his water meter. We found that they had delayed in responding to his complaints and in obtaining his water meter readings, as well as asking him to provide information that he had already sent to them. We upheld this complaint.

Recommendations

We recommended that Business Stream Ltd:

• issue a written apology for the failure to deal with Mr C's complaints appropriately.

Summary

Following a leak in 2010, Mr C discovered that his business premises shared a water meter with a neighbouring property. His business had been charged for the water supply to both businesses for several years without his knowledge. Once the situation was brought to Business Stream's attention, they offered Mr C a credit amount. He complained, however, that the amount was not adequate and that he should receive a refund of 50 percent of the water charges over an eight year period. Mr C raised further concerns about Business Stream's handling of his complaint and the fact that he was charged recovery fees and pursued for outstanding payments when his account was supposed to be on hold while his complaint was investigated.

Our investigation found that, generally, it is the property owner's responsibility to familiarise themselves with the pipe and water meter infrastructure supplying their premises. However, the evidence submitted to us showed that Mr C had specifically asked in 2006 whether his meter was serving two properties. Scottish Water inspected the meter and advised that it only served his property and we considered it reasonable for Mr C to accept this advice at face value. We did not find it appropriate for Mr C to be affected financially by Scottish Water's inaccurate information.

Although the meter was serving two properties, we did not consider that it was necessarily the case that both businesses would use the same amount of water. As such, we did not consider a 50 percent refund of all water charges to be appropriate. Mr C's meter was split in 2010 and accurate readings were available to assess his typical daily usage. When calculating the credit offered to Mr C, Business Stream applied the recalculated typical daily usage back to the date his account was created. We found this to be an appropriate gesture.

We did, however, find that Business Stream inappropriately continued to issue reminder invoices and late-payment fees to Mr C when his account should have been suspended. We were also critical of them for initially misunderstanding Mr C's complaint, and contributing to a delay in the matter being resolved.

Recommendations

We recommended that Business Stream Ltd:

• pay Mr C £40, in line with their service standards, for the delay to his complaint being resolved and the failure to issue a final response; and
• apologise to Mr C for the issues highlighted in our investigation.

Summary

Business Stream contacted Mr C asking for details of his business so that he could be billed for water. He was initially reluctant to provide the requested details but after further discussions, Business Stream issued his first bill. Mr C was unhappy to find that this was for a substantial sum, as it had been backdated to when his business moved into the premises. He complained about the way Business Stream went about setting up his account and about the way they pursued him for water charges dating back several years, despite the absence of previous bills.

We found that the property had previously been occupied by another business, who had told Business Stream when they moved out. The property was, therefore, classed as vacant from that date and Mr C had a responsibility as the new occupant to make arrangements to pay for the water supply. We acknowledged that Mr C may not have been aware of his obligations due to changes that had been made to the water industry shortly before he moved into the property. However, we did not find that Business Stream had any obligation to actively check whether a new occupant had moved in. They had identified Mr C's business during a routine audit of vacant sites, and we found it was appropriate for them to contact him at that point.

Mr C had challenged the accuracy of meter readings that were taken during the period that his property was believed to be vacant. We accepted professional advice indicating that the amount of water used was in line with what would be expected for a property of this size and type. We also noted that a single water bill had been issued, with the first and most recent readings not being in dispute. As such, whilst Business Stream were unable to provide evidence that each meter reading was accurate on the date attributed to it, we were satisfied that the correct amount had been charged for the water that was used.

We were, however, critical of Business Stream for continuing to pursue Mr C for outstanding payments whilst his complaint was being investigated and the amounts were in dispute.

Recommendations

We recommended that Business Stream Ltd:

• apologise to Mr C for continuing to pursue him for payment whilst his dispute was being investigated;
• contact Mr C with their offer of setting up a payment plan; and
• ensure that any late payment fees applied to Mr C's account to date are removed.

Summary

Mr C was spoken to by prison officers when he visited his friend in prison. He was told that a member of staff had said that his behaviour made them uncomfortable. He later phoned the prison governor to complain and then wrote to him about the matter. He considered that the governor’s response did not adequately address his complaints.

We upheld two of Mr C's three complaints. We found that the governor had issued a response after speaking to Mr C, but before he received his written complaint. Although the governor did not consider that the written complaint raised any new concerns, we found that the initial response did not adequately address some of the issues Mr C raised. At the very least, the Scottish Prison Service (SPS) should have contacted Mr C to check if he wanted a further response in addition to the initial response. The governor also failed to address these issues in further responses to Mr C.

Mr C also said that the governor failed to provide him with accurate information in his responses. We did not find any evidence of this. However, Mr C said that the SPS held a file which incorrectly said that he was a registered sex offender. We did not find any evidence of a file, but in their response to our enquiries, the SPS told us that Mr C was a registered sex offender. However, they subsequently confirmed that this was incorrect.

Mr C was warned about comments that he made in correspondence about a member of staff. He continued to make comments about the member of staff and the governor told him that he would no longer be able to visit any prisoner in the prison. The decision to ban Mr C from visiting the prison was one that the SPS were entitled to take (ie a discretionary decision). The SPSO Act says that we cannot question discretionary decisions when there is no evidence of administrative error. We found no evidence of administrative error by the SPS in reaching that decision.

Recommendations

We recommended that the Scottish Prison Service:

• issue a written apology for the failure to adequately address Mr C's complaint;
• make the relevant staff aware of our finding on this matter;
• review the case to identify how they can prevent inaccurate information from being recorded about ex-prisoners in similar circumstances; and
• issue a written apology for incorrectly stating that Mr C was a registered sex offender.